In the Maghreb, organ failure constitutes a major public health problem, especially given the increasing number of patients with chronic renal failure and the high cost of care. In this study, we attempted to seek the recommendations, through a questionnaire, of various officials related to organ transplantation as well as leaders of ethics committees and religious groups in different countries of the Maghreb. The objective was to improve the rate of organ donation and transplantation. We received 36 replies (62%) within the prescribed time limit. In our survey, 83% of the respondents felt that living donor transplantation should be promoted initially, followed gradually by measures to increase cadaver donor transplantation to achieve a target of about 30 transplants with cadaver kidney donors per million inhabitants. To expand the donor pool, 83% of the respondents proposed to expand the family circle to include the spouse and inlaws. To improve the cadaver donation activity, one should improve the organizational aspects to ensure at least 50 renal transplantations per year (100%) and provide material motivation to the treatment team proportional to the activity of organ donation and transplantation. Finally, 93% of the respondents suggested suitable moral motivation of the donors.

In the Maghreb region, organ failure is a major public health problem given the increasing number of patients with end-stage renal disease (ESRD) and the high cost of care. Organ transplantation is the ideal treatment for organ failure; it can save lives in patients with cardiac failure and liver failure and improve patient survival and quality of life in patients with ESRD. Organ transplantation also reduces the cost of treatment in these patients, especially after the second year of transplant.

This cross-sectional study was conducted to highlight recommendations for improving organ donation and organ transplantation, particularly renal transplantation, in the Maghreb. The following objectives were specified:

assessing the potential donor and to ensure the formalities related to living and cadaver donors,

expanding the donor pool,

improving reward gifting in an organized manner,

defining the procedures for increasing the value of donors and their families.

Materials and Methods

Our study is a cross-sectional study based on sending a questionnaire. These questionnaires [Table 1] containing a series of questions relating to the objectives of our study, were sent electronically to the following personnel in various North African countries:

The questionnaire was sent to 58 persons in various countries of the Maghreb. We received 36 responses within the prescribed time limit, representing a rate of 62%. The different responses are summarized in [Table 1]. We did not receive any response regarding transplantation of the liver, heart and lung. Thus, our study related mainly to kidney donation.

Discussion

In our study, the need for kidneys for transplantation was expressed variably as 10, 30, 60 and 100 per million inhabitants. In the Maghreb, organ transplantation programs that were initiated in 1985 still remain below expectations. With regard to kidney transplantation, only 1,000 kidney transplants have been performed during the last 20 years. [1],[2] The activity of organ harvesting and transplantation in the Maghreb is summarized in [Table 2].

Table 2: Activity of organ harvesting and transplantation in the Maghreb until 2005.

In 2005, an average of six kidney transplants per million inhabitants was performed in various developed countries of the Maghreb. This figure is significantly short of the actual needs and does not help, in any way, to shorten the long waiting time for our patients. In Western countries with a long history of renal transplantation, the number of kidney transplants is between 50 and 60 per million population (pmp). To achieve the goal of 60 transplants pmp, we should increase our current transplant activity by about 10-fold.

The proportion of transplants from living or cadaver donors depends on factors such as prevailing religious considerations within a country, legal requirements, experience of the team and the degree of organ shortage. In the Maghreb, almost all kidney transplants are being performed from living donors: 100% in Morocco and Libya, 98% in Algeria and 70% in Tunisia. This predominance of living donor transplantation is also observed in other Muslim countries like Saudi Arabia and Iran. [3],[4] This is in contrast to the US and most European countries, where cadaver donor transplantation represents 60-90%. [5],[6],[7]

In our survey, 83% of the respondents felt that transplantation from living donors needs to be promoted first. Following this, transplantation from cadaver donors may be promoted in a gradual manner with a goal of achieving a rate of 40-50%, which is about 30 transplants by a cadaver kidney donor per million inhabitants.

In Tunisia, to achieve this goal, it is necessary to increase the organ harvesting activity from at least 20 cadaver donors [Figure 1]. Harvesting several organs from the 20 brain-dead individuals can ensure transplantation of all patients in the waiting list for heart, liver, lung and pancreas transplants.

Figure 1: Number of renal transplant by MH according to living or deceased donor in various countries in 2005.

In the Maghreb currently, it is logical to increase living donor transplantation. The circle of living donors, which was initially limited to parents and collateral descendants, has been extended to other related donors such as grand parents, cousins, etc. This expansion of the living donor pool encompasses the bonds of marriage, especially spouses and other members of the in-law family. [8],[9] The search for living donors must be initiated upon diagnosis of renal failure before beginning dialysis, to consider pre-emptive transplantation. At the stage of advanced chronic renal failure, the search for living donors is a therapeutic target apart from hemodialysis or peritoneal dialysis. The search for living donors must be pursued in dialysis centers. [10],[11],[12]

Educating the patient and his family in search of living donors must be provided in hospitals and also at home by a trained team. This education at home can increase, by at least 33%, the number of donors compared with simple hospital education. [13],[14] Exchange kidney transplantation in ABO-incompatible or -positive cross-match cases would be an option for some patients and can recruit an additional number of donors. [15] It would be required to establish a waiting list for kidney exchanges. Furthermore, regarding unrelated living donors, a gift for a loved one or altruistic donation, all respondents in our survey were reluctant and drew attention to special precautions before accepting such practices to avoid any marketing. It is logical to establish a committee of experts whose mission is to analyze the nature of unrelated organ donation.

Finally, the regulated sale of kidneys, even those organized by the government or other agencies, as is advocated in Iran, should not be considered for ethical considerations. [16],[17],[18] In the Maghreb, cadaver donor renal transplantation remains rare; it is 6% in Algeria and 30% in Tunisia. There are no religious obstacles in different countries of the Maghreb to organ donation. Similarly, there are no legal obstacles, but explicit consent is mandatory. About 80% of the respondents suggested revising the legal text: the absence of refusal when the patient is still on life support should mean agreement for donation after death; it is implied consent.

However, some measures would encourage organ harvesting from cadaver donors as follows:

Increasing awareness regarding organ donation: this education should be conducted by specialized associations and should be directed primarily to children. [19],[20]

Spreading the message about organ donation in primary education, secondary education, mosques, newspapers, radio and television.

Accept marginal kidneys: we can expand the list of cadaver donors by including elderly patients with moderate hypertension, diabetics without nephropathy, kidney with anatomical abnormalities and use of kidneys carrying HbsAg or hepatitis C virus antibodies. [23],[24],[25]

Include harvesting from non-heart beating donors. This would enable the removal of kidneys, liver and possibly lungs. Potential donors are victims of accidents, suicide, cerebral anoxia, cerebral hemorrhage or irreversible cardiac arrest. [26],[27]

These measures will help in increasing transplantation activity. Implementation of these measures requires improving the organizational aspects, namely:

Facilitate the identification of the living donor: 100% of our questionnaire responses called for shorter duration of ospitalization, punctual dates for complementary examinations and special monetary discounts for all tests. [30]

Introduce laparoscopy for the removal of living donor kidneys, which can reduce the average duration of convalescence and operative complications such as bleeding and pain. [31],[32],[33] However, this technique is associated with longer warm ischemia time compared with open surgery and a higher rate of ureteral complications. [34],35

Equip the transplant units appropriately by having a suitable number of medical and paramedical staff.

Improve the structure and conditions for handling brain-dead donors.

Finally, a constant response was to motivate the transplantation team: well-paid night nurses as well as all medical and paramedical personnel involved in transplantation activities and ensuring training courses and internships in experienced teams across North Africa and abroad.

Finally, it is important to motivate the donor and his/her family to encourage the donation:

We must offer moral motivations for living donors: periodical decoration ceremonies.

The living donor should be offered other kinds of motivation, such as: overcoming constraints (paid leave), priority recruitment if unemployed, free medical care and ensuring insurance coverage.

Expressing gratitude to the donor's family (brain-dead donors).

Facilitate the administrative procedures to discharge the deceased donor, transportation and funeral.

The majority of colleagues agree that the donation must be gratuitous and altruistic.

In the Maghreb, organ donation and transplantation should be seen as a national priority health problem because of the high cost of care of organ failure, and especially of chronic renal failure. We should take appropriate measures to expand the donor pool. There should be concomitant improvement in the organizational aspects as well. Finally, awareness, training and well-established dissemination of information will improve the donation.